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Research Highlight

Enhancing Primary Care to Serve Veterans with Serious Mental Illness: SMI PACT

Health care systems are interested in identifying patients at high risk of hospitalization or poor outcomes and proactively improving their care. This high-risk patient population includes a large proportion of individuals with mental illness or substance use disorders. Individuals with serious mental illness (SMI) have not benefited from improvements in prevention and primary care that have reduced mortality in the rest of the population over recent decades. While Veterans with SMI have better medical care and outcomes than individuals with SMI who do not have access to VA, substantial disparities remain between the care of Veterans with and without SMI.

Evidence indicates that individuals with SMI have difficulty accessing health care and managing their complex comorbid conditions. This population has diminished quality of life from chronic diseases. In VA, the overall prevalence of type 2 diabetes in individuals with schizophrenia, the hallmark SMI disorder, is 26 percent, while the rate in individuals with schizophrenia nationally is 16 percent, and in the general population it is 5 percent. Also, people with SMI have significantly elevated rates of obesity, smoking, and other metabolic risk factors. More than 60 studies have found that mortality rates among individuals with SMI are two to three times greater than in the general population. When studied in VA, all-cause mortality risk was found to be 1.4 for depression, 1.3 for bipolar disorder, and 1.6 for schizophrenia. In VA, the number of Veterans with SMI has risen every year since fiscal year (FY) 1999. Total health care costs for Veterans with psychosis were approximately $4.6 billion in FY 2008. These total costs represent an increase of 13 percent from FY 2007 to FY 2008, with the majority of costs arising from non-psychiatric care.

What Primary Care Models are Effective?

Although VA provides centrally organized, comprehensive health care, Veterans with SMI still have difficulty navigating the system. Too often, they do not attend appointments or fail to engage in primary care treatment, and do not receive valuable preventive and primary care services. The VA Primary Care-Mental Health Integration initiative has addressed Veterans' mental health conditions by co-locating mental health clinicians in primary care settings, and by making care management services available in these settings for common psychiatric disorders. This has focused on patients with depression and anxiety, with the goal of managing these patients within primary care, freeing up specialty mental health services for patients who need them most.

The next step is to transform the health care of Veterans with SMI. Some VAs have co-located primary care clinicians within specialty mental health settings. However, this co-location has not been implemented widely, and researchers have found that it has inconsistent effects on care processes and outcomes. Treatment processes, in particular, need to be improved to address patients' complex needs. A modest number of research studies have examined the effectiveness of care models for improving the medical care of people with SMI. Models have included co-location, team-based care, and facilitated referrals to primary care. While there have been some positive effects, implementation has varied, and it is difficult to know which models are effective. The few economic studies in this area have often found models to be cost-neutral or cost-reducing from the perspective of the health plan. One particularly promising team-based model includes medical care management, in which highly competent clinicians provide proactive care to a defined panel of patients. Evidence also supports the efficacy of collaborative care to improve treatment for people with SMI.

VA's Patient Aligned Care Team (PACT) model can include care coordination, patient-centered care, and use of clinical data to proactively manage populations. It seems likely that PACT can be tailored to meet the needs of Veterans with SMI by applying the evidence on medical care management and collaborative care.

SMI-PACT: A Primary Care Model for those with Serious Mental Illness

VA HSR&D QUERI is supporting a project to implement and evaluate a specialized PACT model that meets the needs of individuals with SMI ("SMI-PACT"). The SMI-PACT team is led by a primary care provider. Tailoring of the PACT model includes a smaller panel size (patient n=500), in line with VHA Handbook 1101.02 directives for specialty PACT, allowing an increase in standard visit length from 20 to 30 minutes. Both the SMIPACT registered nurse care manager and primary care provider are trained in the needs of this population, including frequent outreach between appointments and aids to support education around illness self-management. A psychiatrist consults to the SMI-PACT team.

In a site level-controlled trial, SMI PACT is being implemented at one medical center, and compared to existing PACT teams for people with SMI at two other medical centers within the same VISN. The project is studying the effect, relative to usual care, of SMI-PACT on: provision of appropriate preventive and medical treatments; patient health-related quality of life and satisfaction with care; and medical and mental health treatment utilization and costs. The project includes a mixed methods formative evaluation to strengthen the intervention and investigate relationships among organizational context, intervention factors, and patient and provider outcomes as well as to identify factors related to successful patient outcomes. This is one of the first projects to systematically implement and evaluate a medical home model for this population.

References

1. Walker ER, McGee RE, Druss BG. "Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis," JAMA Psychiatry 2015; 72(4):334-41.
2. Chwastiak LA, et al. "Association of Psychiatric Illness and All-cause Mortality in the National Department of Veterans Affairs Health Care System," Psychosomatic Medicine 2010; 72(8):817-22. 3. Druss BG, von Esenwein SA. "Improving General Medical Care for Persons with Mental and Addictive Disorders: Systematic Review," General Hospital Psychiatry 2006; 28(2):145-53.